CSAM-SCAM Fundamentals. Cocaine Basics. Presentation provided by David C. Marsh MD CCSAM

Transcription

1 CSAM-SCAM Fundamentals Cocaine Basics Presentation provided by David C. Marsh MD CCSAM

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3 Chronic Illness Relapsing & Remitting in Course Genetic Predisposition Individual Choice a Factor Environmental Influence Potentially Fatal If Untreated Prevention Is Possible Properly Managed Can Lead Normal Life

4 Response Rates Drug and Alcohol Treatment 40-60% abstinent at 1 year (vary with drug) Best outcomes in those maintained in MMT or Participating in on-going Mutual Support Diabetes, Hypertension, Asthma 40-60% medication compliance <30% adherence with diet and risk reduction 50% symptoms require medical intervention within 1 year McLellan, Lewis, O Brien and Kleber (2000) JAMA 284:

5 Cocaine Effects Blocks Catecholamine Reuptake Dopamine, Noradrenalin, Adrenaline Euphoria Increased Energy Insomnia Anorexia Hypertension and Tachycardia Often combined with Alcohol to Prolong Effect

6 Cocaine Problems Multiple Organ Systems Damaged By Restriction of Blood Flow and Increased Metabolic Demand Myocardial Infarct or Arrhythmias Multiple Small Cerebral Infarcts Frequently Increased Sexual Risk Behaviour Risks Associated with Route of Use Smoking/Snorting Respiratory Damage Blood-Borne Illnesses passed by Sharing Implements Injection Local Sequelae including Infections Systemic Infections (Bacterial, Fungal, Viral)

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12 # correct in 45 sec Stroop Task Improvement During Methamphetamine Abstinence Control (n = 141) * < 72 h n = 86 3 Months n = 19 *p < 0.05

13 Depression In Methamphetamine Abusers BDI Score Control scores = Weeks of Abstinence

14 Time (msec) % Correct Methamphetamine Abusers Show Impaired Attention * Reaction Time Accuracy *p<0.05

15 Cingulate Cortex In Methamphetamine Abuse Anterior Cingulate Posterior Cingulate

16 Glucose Metabolism (mg/100 g/min) Reaction Time Correlated To Angular Gyrus Metabolism In Methamphetamine Abusers CONTROL METHAMPHETAMINE r = r = 0.92 p < 0.05 Reaction Time (msec)

17 Emergency Management of Intoxication Stabilize Vital Signs (ABC s) Rule Out or Treat General Medical Conditions Diabetic Coma Subdural Haematoma Seizures Pneumonia Meningitis GI Bleeding

18 Subacute Management of Intoxication Provide a Reality Base Use names often State location repeatedly Non-Verbal Support Frequent, brief eye contact Relaxed posture Constant Subdued Lighting Never leave alone Always Check for Pregnancy Opiate Withdrawal in pregnancy can precipitate miscarriage

19 Pharmacological Treatment of Withdrawal (General Approaches) Symptomatic relief Cross-tolerance with longer half-life agent Less reinforcing and less dangerous mode of delivery of drug

20 Withdrawal Management and Treatment Treatment of Withdrawal is Not Treatment Patients with Substance Dependence requiring withdrawal management all require treatment Outpatient Counseling Intensive Day Treatment Intensive Residential Treatment Short-Term Residential Transitional Treatment Long-Term Residential Treatment Supportive Housing

21 Pharmacotherapy For Continuing Care (Broad Strategies) Pharmacological Avenues Aversion Decreased Appetite Decreased Reinforcement and Extinction Relapse Prevention Antagonist maintenance Long Acting Agonist Maintenance Prevent Complications In Face of Use

22 Oral Amphetamine Maintenance for Cocaine Dependence Pilot Study for 14 weeks (16 Pts. 60 mg/day; 14 Placebo) Treatment retention was equivalent between group Cocaine-positive urine samples treatment group declined from 94% to 56% compared no change in the placebo group (79% positive). treatment group reduced self-reported cocaine use (P= 0.02) reduced criminal activity (P=0.04) reduced cravings (P<0.01) reduced severity of cocaine dependence (P<0.01) no within-group improvements found in the placebo group Shearer J et al (2003) Addiction 98:

23 Pilot Studies of Medications for Cocaine Dependence in Heroin-Assisted Treatment Nuijten et al (2011) BMC Psychiatry 11:135

24 Topirimate for Cocaine Dependence Poor compliance with medication Limited benefit Nuijten et al (2015) Drug Alc Dep 138:177

25 Modafinil for Cocaine Dependence Poor compliance with medication Limited benefit unless high adherence Nuijten et al (2015) J Psychopharmacol 29:678

26 Fundamentals: Cannabis Dependence Summary Cocaine is highly reinforcing Dependence can be devastating to function but most users do not progress to dependence Treatment is challenging Relies on Psychosocial Interventions Medications should be primarily within context of clinical trials until proven effective